Advance planning helps families cope with loss

In a randomized trial, hospitalized patients over age 80 who were formally assisted with documenting their end-of-life treatment wishes and with designating a surrogate were almost three times more likely to have those wishes followed (86% versus 30% in usual care, P<0.001).

Family members of patients in the advance planning intervention reported significantly less emotional trauma afterward, Karen M. Detering, MBBS MHlth Ethics, of Austin Health in Heidelberg, Victoria, Australia, and colleagues reported online in the BMJ.

These results are a far cry from the “death panel” fears sparked during American healthcare reform debate, commented Sharon Brangman, MD, chief of geriatrics at the SUNY Upstate Medical University in Syracuse, N.Y., and president-elect of the American Geriatrics Society.

An early provision in the House bill would have required Medicare to start paying for end-of-life consultations for patients who wanted one.

“The language about ‘death panels’ was very inflammatory and was to serve a political purpose,” she told MedPage Today. “This is not doing something to ‘pull the plug’ or do other things that have been [reported by] the media.”

End-of-life consultations could actually save the healthcare system money by eliminating unnecessary testing and procedures that patients don’t want, but the focus is really on ensuring patients’ wishes are known and met, Brangman emphasized.

Even without Medicare coverage, geriatricians and others continue to have these time-consuming conversations, she noted, calling it a “gift” to family members.

Detering’s group noted an increasing awareness of how poor the knowledge is about patients’ wishes after they lose the capacity to express them.

They randomized legally competent patients ages 80 and older admitted to their single-center university hospital to receive either usual care or an intervention for advance care planning facilitated by a nurse or allied health worker. The 80-and-over group accounts for more than half of deaths at the facility.

In the intervention, patients were encouraged to include their families in reflecting on goals, values, and beliefs and then document their wishes about end-of-life care, such as the wish for life-prolonging treatments and cardiopulmonary resuscitation.

These discussions averaged 60 minutes over one to three meetings. Treating physicians participated as needed to make sure patients understood their illness, treatment options, and likely prognosis.

Usual care did not include any advance planning unless specifically requested, which one patient did (0.6% versus 81% rate of completion for advance care planning, P<0.001).

During six months of follow-up, mortality rates were similar between groups, “which discounts the suggestion that advance care planning may be promoted as a mechanism to limit medical treatment,” Detering’s group wrote in the BMJ.

Deaths in the intervention group were substantially more likely to have been under conditions in which the patients’ end-of-life wishes were known and respected (25 of 29 versus 8 of 27, P<0.001).

Patient involvement in that end-of-life decision-making was also more likely with facilitated advance planning (74% versus 48%, P=0.02).

Patients (or their family members, if patients died during hospitalization) reported being “very satisfied” with all aspects of the hospital stay, including involvement in decisions, how well they were listened to, and information provided to them, significantly more often with the intervention (all P<0.001).

In the families of these patients who died, advance end-of-life planning was associated with:

* No cases with a score over 30 on the impact of events scale, indicating post-traumatic stress, depression, and anxiety, compared with 15% in the usual care group (P=0.03)
* Lower anxiety scores (P=0.03)
* Lower depression scores (P<0.001)
* Higher satisfaction with the quality of their family member’s death (P=0.02)
* Higher perceived patient satisfaction with quality of death (P<0.001)

Limitations of the study included that it was conducted at a single center, obvious patient group assignment to those recording the answers to the questions, and lack of inclusion of non-English speaking or noncompetent patients.

The researchers noted that prior studies have shown that patients’ end-of-life wishes are not always respected when documented, whereas their results were different, likely because the model included correctly filed documentation and systematic education of physicians.

They noted that use of nurses and allied health staff overcame the barrier of limited physician time and said that the model would likely be generalizable to other healthcare settings.